A Novel Application of Vacuum-Assisted Closure in Auricular Reconstruction

Abstract

Sir: Auricular reconstruction is a challenge for the reconstructive surgeon. In the majority of cases, autogenous costal cartilage grafts are used as scaffolds for the overlying soft-tissue envelope. Critical to all currently used techniques is adequate protection of the graft from infection and edema during the early postoperative period. Brent described a suction drainage system with two thin catheters within the tissue envelope to facilitate redraping of the skin to the underlying cartilage framework.1 The drains were attached to vacuum blood sample tubes. However, some disadvantages are evident. First, the negative pressure inside the vacuum tubes varies between tubes and is impossible to quantify. Tubes must be changed every 2 to 3 hours over the initial 3 to 4 postoperative days (i.e., 24 to 48 times in total). This leads to repeated windows for loss of vacuum pressure, each causing shear forces across the fragile graft. Changing tubes adds an unnecessary workload for already busy nursing staff. We propose a novel application of the vacuum-assisted closure protocol. This system develops the cost-effective technique designed by Brent, but uses a more reliable vacuum apparatus that requires less monitoring. In auricular reconstruction, we follow the two-stage procedure described by Nagata2 and Firmin3 (Fig. 1). Posttraumatic cases are treated with a one-stage procedure. Two 3.2-mm-diameter Redon drainage tubes are inserted, with the first placed within the tissue envelope next to the helix of the cartilage graft, exiting the skin approximately 2 to 5 cm inferior to the lobule. An open-cell sponge is placed over the flap. The second tube rests within a pocket created in the open-cell sponge, and both tubes are connected by means of a Y-junction. The system is enclosed in an occlusive dressing (OpSite; Smith & Nephew, Columbus, S.C.) (Fig. 2). The vacuum complex is connected in the operating room to a 3.2-mm Porto-Vac drain (Stryker Instruments, Portage, Mich.) and then clamped and transferred to wall suction in the ward. Negative pressure is kept at the minimum level required to eliminate dead space inside the soft-tissue envelope (120 to 150 mmHg). The vacuum-assisted closure system is left undisturbed for 4 to 5 days on the ward before being changed to a nonvacuum dressing for an additional week.Fig. 1.: A patient with unilateral microtia before surgery (left) and after stage 2 (right).Fig. 2.: Intraoperative view showing our adaptation of the vacuum-assisted closure technique.The proposed adaptation of the vacuum-assisted closure technique has several advantages. The contour of the reconstructed auricle is visualized in theater and maintained over the following days, facilitating coaptation. This eliminates the issue of irregular contour for flap-scaffold apposition. Second, edema is reduced, improving vascular perfusion and lymphatic flow and reducing potential bacterial load.4 These factors act in concert to improve take of the reconstructed auricle complex. Intervention required from ward staff is reduced, as vacuum systems are untouched for 4 to 5 days. As in all systems, disadvantages do exist. The primary disadvantage is increased length of ward stay, as patients must stay in proximity to the central vacuum system. In a private hospital setting, a commercially available mobile vacuum-assisted closure system (V.A.C.; KCI, Inc., San Antonio, Texas) has been tested successfully in similar patients, with the advantage of enhanced patient mobility with monitoring on an outpatient basis. Our suggested modification demonstrates a novel application of the vacuum-assisted closure technique and has been proven safe and simple to apply and provides excellent reconstructive outcomes. Frank R. Graewe, M.D. Division of Plastic and Reconstructive Surgery Stellenbosch University Cape Town, South Africa Richard J. Ross, B.Sc.(Hons.) School of Medicine Faculty of Health Sciences Flinders University South Australia, Australia Tim Perks, M.D. Chris van der Walt, M.D. Alexander E. Zuehlke, M.D. Division of Plastic and Reconstructive Surgery Stellenbosch University Cape Town, South Africa